So far the comments have been about people's prior experiences with the topic (which is great), or prior opinions about the topic (which is ok). But the more interesting story is being overlooked: this is heavy-duty new research that overturns previous conclusions, including the prior expectations of at least one of the lead authors. It would be good to discuss the specifics of the article and the new study.
Do you think you could elaborate why you believe this is "heavy-duty" new research (or even new research at all, rather than a new meta-analytic synthesis of old research)?
My quick read of the study suggests that they examined several outcomes, got null or low powered results on most of them, and chose to highlight the single result which did show a significantly positive effect on recovery; that result was based on a meta-analytic estimate of the pooled sample of just two studies. In particular, my understanding is that this study found a null on "percentage days abstinent", a null on "longest period of abstinence", a null on "drinks per drinking day", a null on "alcohol-related consequences". For alcohol addiction severity they report the results of one study without doing any original analysis. And for "rates of continuous abstinence" they found a positive effect. In most cases these are graded as "low certainty evidence". The positive effect is claimed to be "high certainty evidence", but the CI / p-value for the positive effect is not adjusted for multiple comparisons -- I don't think that's fatal, but it does speak to the fragility of the outcome.
The other concern I have is that they separate "manualized" treatments (e.g. AA treatments administered according to a protocol) from "non-manualized" (e.g. ad hoc administration of the AA treatment) treatments. This is fine -- we would expect to see that if something about the protocol was useful, the non-manualized treatments would display an attenuated version of the same effect. Instead we get a null on the original positive effect, and a positive effect on one of the original nulls
Finally, the authors seem a little loose with what the comparison groups are. They claim they recruited studies which compared AA to no treatment, but the results are all motivated as being AA versus CBT. What happened to the no treatment studies? Perhaps these are buried in the full text. The rate of spontaneous remission of addiction is believed to be fairly high and most of the past criticism of the efficacy of AA has been motivated by comparison to spontaneous remission.
It strikes me that there is significant distortion of the study findings from the Cochrane write-up to the Stanford press release, and from the Stanford press release to the NYT piece, and that in both cases the distortion is in favour of claiming the study has found affirmative evidence that AA works better, rather than just no evidence to claim it works worse. For instance, one of the thrusts of the NYT piece is that the past Cochrane review was based on a limited number of studies... but the operative finding in this review is based on an even more limited number of studies, even if the pool of studies from which they drew has become larger over the last 15 years.
All of this is from a quick read of the review -- I am off campus right now and don't feel like VPNing or pirating the full text to deep dive the analysis.
> And for "rates of continuous abstinence" they found a positive effect.
It’s been a while since I reviewed the literature for substance abuse disorder, but if I remember correctly it was highly disputed whether complete abstinence was necessary (or even beneficial) for treatment. Has this changed?
The argument was that by focusing on abstinence you are setting a significant part of your patience up for failure with all the psychological harm involved in knowing that they’ve failed, which might result in severe and frequent relapses.
EDIT: To conclude. I find it hard to draw conclusions if success is measured in “days of abstinence”. That means that a patient that has recovered from cognitive behavior therapy (CBT) that uses occasionally and non-detrimentally is not considered a success! Further AA or other 12-step programs do often stress abstinence while CBT does not, this creates a counting bias in favor of 12-step programs.
I'm a recovering information addict, food addict, sex addict, and love addict.
Doing the same behaviors in a mindful way instead of out of a desire to mask/numb/avoid matters.
Also, I stopped counting my various abstinence stretches because it's not actionable information. I don't assess my recovery that way. I take a look at my needs and identify how I'm doing meeting them.
That initial honeymoon period? It’s like it fixes everything. I’m a whole different person.
Then the honeymoon period ends and I get bored and irritated and nasty. I need to find another one to fix me. Because the current relationship is clearly where the problem lies.
Repeat ad infinitum.
That’s my experience of it. Others may have a different experience.
I am very skeptical about claims that heavy alcoholics can ever moderately drink over a significant period of time again. There are a lot of studies showing successful moderate drinking over the short term, but the studies are always short-term studies using self-reporting data.
Active alcoholics are downright dishonest about how bad their alcoholic drinking is; they will claim it is moderate drinking to anyone who asks them (including scientists making a study) and lie about the amount of alcohol they actually consume.
The most famous study refuting the claims that alcoholics can moderately drink again is probably Pendery 1982, which showed that people who were reported as successfully moderately drinking in an early 1970s study were, a decade later, either not drinking at all, engaging in out of control drinking, or dead from alcohol-related complications.
The question is not whether “heavy alcoholics can moderately drink”, which you claim skepticism over, and I—for the record—claim ignorance.
The question is: “is complete abstinence necessary for some cases of substance abuse disorder?”
We have ample observational evidence that complete abstinence does relieve many people from the symptoms of substance abuse disorder. We also have some anecdotal evidence that that is not true for everyone.
I also have a problem with the term moderate drinking. I’m sure—although here I’m ignorant as well—that patients aren’t encourage to moderately drink. Rather they are—again I’m guessing—not told to have failed if they do drink.
Say a recovering alcoholic has a night out of heavy drinking, but that does not further negatively impact them, i.e. they won’t relapse into a constant drinking habit. I would hold on calling that a failure. In fact it might be actively damaging for their psychological well being to say that they failed, which might actually cause a severe relapse.
The statement “by focusing on abstinence you are setting a significant part of your patients up for failure” sounds like advocating “moderate drinking” to me.
If we’re not telling alcoholics that abstinence is the goal, we’re telling them they can “moderately drink”. “moderate drinking”, simply put, is what we call non-abstinence for alcoholics.
This is very different from saying that a one-day relapse is a complete failure, and, yes, I agree that Alcoholics Anonymous is too focused on raw sobriety time.
> The statement “by focusing on abstinence you are setting a significant part of your patients up for failure” sounds like advocating “moderate drinking” to me.
Sorry, that was not my intention. Like I stated earlier in the thread, it’s been awhile since I reviewed the literature. I’m not a psychologist, and I’m neither a recipient nor a practitiner of Cognitive Behavior Therapy for Substance Abuse Syndrome.
That said I’m sure therapists have a way of negatively reinforcing the damaging drinking behavior in such a way that a single night out is not considered a failure. I don’t know how they do it, but they are experts and I’m sure they know how to.
Thanks! That's a fabulous comment. By "heavy duty new research" I was just referring to this from the article:
In the last decade or so, researchers have published a number of very high-quality randomized trials and quasi-experiments. Of the 27 studies in the new review, 21 have randomized designs. Together, these flip the conclusion.
That sounds impressive. If it turns out not to be so impressive, that's definitely on topic.
This reply will probably be ignored, since it has been two days and ycombinator has a pretty short attention span, but I have skimmed over the full study.
There are about 10 findings, and the only “high” quality finding is that there appears to be a significant increase in abstinence, especially long term abstinence from people who get treatments which get them in the rooms of AA (“TSF” treatments).
We can dive down in to the details about this finding (percent abstinent) on pages 88 and 89 of the report. They actually use six different studies, but only two of them provide information at the one-year follow-up, so only those two get listed in the summary on page 4 of the report.
Considering that they compared a number of things, and only percentage of subjects abstinent showed, with high confidence, a difference between AA/TSF and other treatments, I’m a little worried we may be seeing a multiple comparison fallacy. Then again, this is unlikely: They are seeing P values of 0.02 and 0.03 (1-in-30 to 1-in-50) for the abstinent numbers, but only look at about 10 factors.
Humphreys 2014, another meta-analysis of multiple studies, showed AA effectiveness which can not be attributed to self-selection, but it saw something different: A fairly small but significant increase in the percentage of days abstinent. While they did see in the 2020 Cochrane review, they did not see it with a high level of confidence (see pages 89-90).
Percentage days heavy drinking — I don’t have a copy of Brandsma 1980 handy, but I think that’s what the “Brandsma 1980 shows that AA results in increased binge drinking!!!111!!!!!” claim parroted by the usual anti-AA crowd talks about — might be increased in the short term after starting AA treatment, based on the one study which has 6-month follow-up figures for this; Brandsma 1980 only saw it at the 3-month follow-up and not later. Then again, the Cochrane study of those numbers show a pretty high P value (0.79, just glancing at those figures), which means we still don’t really know if Brandsma 1980 actually saw something. Scott Alexander dismisses it as an example of a multiple comparison fallacy, and the P values for it in Cochrane 2020 means we probably didn’t actually see something, but this may merit additional investigation.
Cochrane 2020, of course, didn’t look at the longitudinal studies showing really high abstinence rates for people who self-select to go to a lot of AA meetings, but even using only randomized studies, we are seeing a significant increase in number of subjects who get and stay sober when they engage in treatment which encourages AA attendance.
Another thing: There are no recent high-quality studies comparing AA to no treatment (“spontaneous remission”, an expression I see used mainly by people with a pretty strong anti-AA bias) because it’s been established for a long time that AA (or any other treatment you can think of) is better than no treatment. Even Brandsma 1980 saw that going to their AA-like meetings was significantly better than getting no treatment at all.
In summary, with some caveats, we are seeing solid scientific evidence that AA really helps alcoholics get sober and stay sober. Ten years ago, someone could still say “AA does not have a higher success rate than no treatment” with a straight face; today, to claim something like that requires ignoring a lot of scientific evidence.
Sorry for going on a rant here, but I dislike the framing implicit in "spontaneous remission".
Addiction does vanish spontaneously with a wave of a wand. These are people of flesh and blood and free will that managed to overcome their addiction. They are making attempts at treating themselves. They might be reading blog posts with advice. They may avoid buying alcohol for fear they'll drink it all. They be taking detours around bars. They may be meditating or even self-administering cbt.
It's spontaneous because it is not caused by the external treatment. It's not a misnomer so much as a difference in usage. When you say a person did something spontaneously, it means it was impulsive, not caused by anything, and has connotations of being a sudden or easy action. When you say an event was spontaneous, there is no reference to meaning or intensity of the event - it simply means that there was no external cause.
Still, if my physiotherapist tells me to strengthen my core muscles with daily bodyweight exercises and I instead strengthen my core muscles with weekly free weights exercises, if I am cured it would seem odd to call it spontaneous.
The statistical question is whether you would have done those exercises regardless of whether you consulted a physiotherapist. If you would have done those free weights exercises anyway, then it's unreasonable to credit the physio with your recovery; if you wouldn't have done them of your own accord, then it's reasonable to credit the physio even though the precise causal mechanism wasn't what we would expect. We're not trying to address philosophical questions, but find out whether particular treatments have a meaningful effect.
This meta-analysis isn't ground breaking. What has been known for awhile is that AA works very well for some, but not at all for others. This has always been the dilemma with AA in research as well as clinically. It won't affect treatment because no one was ever discouraged from trying it at least in my experience.
